Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Friday, May 21, 2010

Becoming a physician, thirty years ago, did not involve subjecting yourself to extortion. First with Medicare/Medicaid, now with EMTALA, and soon, whatever bezoar is eructated out of D.C., a generation of physicians is being extorted. Furthermore, the impact of the extortion is not limited to physicians, rather, the impact is on all who need health care in America.

First, let me be clear that I am not one of these physicians, but I know lots of them. I know plenty of physicians who signed on the dotted line to commit themselves, body and soul, to medicine. They did it based on one of the fundamental principles of a market economy (and, doubtless, for many other reasons), that a fair price would be paid for excellence, and that their reputation and the price of their services would be determined by the most efficient distributor of resources known, the market. Also, they did it based on the belief, historically accurate in our country, that as a professional’s professional, they would have power over their careers.

It may be incredibly naive for them to have done that. In retrospect, my decision to join the service and have Uncle Sam pay the tab for medical school ($180,000 in 1992 dollars) seems like a genius move, but at the time there was no shortage of folks telling me I was making a big mistake. I joined for reasons other than money, but money was one of the reasons.

Coming out of medical school debt free has allowed me to avoid the trap in which many find themselves. * It seems to be a trap that caught PandaBear and one that has caught many of my friends. The trap is extended and expanded through residency training by paying residents, per hour, minimum wage or less. During residency it is therefore impossible, especially if one has a family, to pay down your loans. Think about the interest over four years, or eight years, on $180,000 and then the size of the trap becomes clear. But the trap is only partially financial. The trap is cruelly protean.

Over the last fifteen to twenty years a quiet coup has taken place in medicine, with decisions regarding physician reimbursement, schedule, responsibilities, and the shape of a physician’s practice being co-opted by all manner of clipboard carrying administrative drones and academicians. Understand, I don’t believe the drones to be evil per se, they are simply doing what we can not… working to support themselves and their families to the BEST possible extent within their comfort zone. But their ‘normal’ existence and the laws, rules, and regulations which have allowed their rise, has come at the direct expense of physicians, and of patients.

The expense to physicians is in money lost from paychecks, but, more importantly, in confidence. The monetary loss is one thing, and it’s not hard to see how it happened… EMTALA and other government redistribution programs are unfunded, medical care comes at a cost, someone must pay, and the people paying the most are providers of the service (physicians), nurses, and taxpayers. Strangely, this redistribution has not only given to the poor (both deserving and underserving) and illegal aliens (by the hundreds of thousands), but has also given, from our pockets, cash to the new drone class in medicine. After all, there has to be a drone class to file the papers and hold meetings about how other people’s resources and money should be distributed. It has to be done with a semblance of “fairness” even though the act is unfair on its face.

Physicians have been a quiet bunch as their stuff has been taken, their time at the hospital increased, their power quashed, and their ability to practice medicine like they trained severely limited. Here is where uncertainty has replaced confidence. Here is where a whole generation of academicians and older physicians have given into bullying, or, worse, encouraged it.

I guess this is not surprising. It’s disappointing, but not surprising. It is one of the essential points of Panda’s post… what choice does he have at this point but to go perform at the carnival even though he belongs on Broadway (my words, not his). And the commentors either deride him for not liking the carnival, deride him for wanting to change it, or deride him for 'not being carnival material’. They say, “Well, leave already!” And go where? And do what? And pay his $3000- in school loans per month (for ten years) with what?

The Queen of the drones understands this calculus. The Queen demands more from the physicians, but the Queen does it in increments. So we physicians, and much of this IS our fault, have never recognized that once we surrendered to an emotional plea to implement price controls on some of our services that the DEMAND togive them away would surely follow. The funny thing is that, as a profession, we used to give away plenty of our services (perhaps more than we do now by law) prior to the rise of the Queen and her drones. Why do you think there are many hospitals called ‘Charity’? All that has happened is that we no longer get to experience the good feelings of providing charity care AND we have taken a pay cut so that tens of thousands of billers, coders, quality control folks, and ‘medical administrators’ can hold endless and pointless meetings which, ultimately and practically, become rules by which we must work. Guess what has happened to medical school tuition in the same time?

There are those who would say the medicine is greatly improved by the meticulous charting requirements and codes etc… I think medicine was better when your good family doctor could see you in his office, spend time with you, take care of you in the hospital, tell you ‘no’ or ‘you are too fat’ without fear of firing, keep your chart on an index card, hire a nurse and a secretary, AND be financially secure by doing this.

Patients complain that their interactions with physicians are limited and unsatisfactory. They are right, but they are unsatisfying for us too. We mightily wish it were otherwise; that we didn’t HAVE to see so many patients so quickly. We are operating in a perpetual crisis mode, but there really is no crisis. A crisis is not running-out of your Lortab. The ambulance is not needed to bring your child in for fever. A crisis is war, famine, drought, tornado, hurricane, heart attack, flood, severed limb, etc… In these circumstances it would be expected (and sensible), for all providers to have to scramble and keep moving, but the crisis is one of perception, and to the extent there is a crisis it is because responsibility for one’s health care bills has, for a segment of our population (which includes those in our country illegally) been eliminated by fiat. It didn’t take long for this to filter through, and now a certain class of patient (including illegals) EXPECT the best care for free. Obamacare seeks to cement this entitlement and it is going to, let me put this gently, KILL a lot of people.

I am not going to be participating in this dance, but I have an easy choice... I have an out now, for real, and I’m taking it. ** I’m taking a pay cut, but taking a lifestyle raise. I will be trading money for sleep and family. I can’t wait. I believe that once my colleagues get to a financial position where this choice is open to them, that most will make the same one that I have, that ‘Cat has, and that an increasing number of Emergency Physicians have. If you don’t believe me simply google “Emergency Department Closures” or “physician shortage” and see what you get.

The ultimate result of the dunderheaded and Machiavellian EMTALA/Obamacare power play will be, unfortunately, to hurt the very folks it was alleged to help, for the rich will always get good care, but when there are too few doctors to go around, the ER will be where poor people and illegals go to die. Through the looking glass, down the rabbit hole.

* For those of you thinking that medical school should therefore be ‘free’, please stop reading and go throw yourselves from a building more than 45 feet above pavement.** I am going to work a 9-5 job which involve a little medicine and a lot of handshaking. More when I start the job.

25 comments:

I usually enjoy your posts. As a prospective med-school student though, you really depress me sometimes. I keep telling myself I'm not in it for the money. Sometimes you make it sound like even a comfortable living will soon be impossible. *sigh*

i usually enjoy your comments.... just kidding there friend. thanks for popping in and saying 'hi'.

let me try to give you a little lift after such a depressing post... you may be, using contrarian thinking, in just the right spot.

first of all, the world will always need doctors. your skills will be in high demand, and you will always be able to find work.

secondly, you go forth a little wiser now (if i may be so bold) about the realities of practicing medicine today in America. you can make choices accordingly.

and some advice. it's going to be very corny. find what you love in medicine and pursue it. it doesn't matter if it's not in vogue at your school or not 'tough' or not 'challenging' or not like running the ironman. choose what you enjoy.

secondly, do not look to medicine, or your career therein, to provide some deeper meaning or prestige or mojo or whatever. for better or worse, today, it's a job. that's all it is.

now you and i probably know differently because we feel that there is something special about what we do... that we practice a noble profession and a giving profession and hopefully that counts for something somewhere. but perceptions, while often wrong, carry weight, and the perception is now, that what we do is just a job, and that health care is a commodity and not an art. this perception may change, but if it does, it will be decades hence.

and lastly, and this is pure money advice, when that guy comes and talks to your medical school class about no fault disability insurance, and tells you it's $80 a month, take it. then, ask your dad or mom or someone you trust, and sit down and make yourself a financial plan.

you can live comfortably, probably always will be able to, being a doctor. but now, more than ever, you will have to plan well. good planning now, less headaches later, and, if you are like me, learning about finance is a bit interesting, and taking hold of your financial future is empowering.

shit, i just said 'empowering', i must be exhausted. time to log off and wish you nothing but the best. come by anytime.

Tony: There are careers that will be more rewarding to your soul than medicine. As 911 said ...it will indeed be decades before a true turn around takes place. A cardiologist friend of mine,out working no more than 10 months since finishing residency, is miserable.The practice of medicine no matter what field is only going to get worse. Sorry to be so negative but sometimes it is better to look at the situation with eyes wide open. You have many options for a career that you will enjoy.

911: All the best to you. Hope this is the govt job you were patiently waiting for.

Yours has been an escape in slow motion, 911, but such is the case when family considerations weigh heavily on your mind. If you were an inmate you would have been captured by now, re-sentenced, re-incarcerated and finally returned to the community to sell drugs. Best of luck, as alway, may the wind be at your back.

I'm a medical student right now pursuing an Emergency Medicine residency. Reading these posts always seem to take 1 more bit out of my soul. I tell myself that after residency I'll only do 12 12s a month to keep my sanity (thank God for my parents having the financial power to help with tuition). After I guess 20 years of 12 12s, I guess I will settle into an Urgent Care center or just become a local WalMart Doctor. I see no harm in selling out to the man...unless you have better ideas for an older ER doc. I'm trying to figure out my future 911Doc, and I'm hoping you can throw your advice my way

I have met only a handful of physicians that I believe went into medicine "for the money" (and one who openly admitted it...he wanted to "pop zits" 3 days a week and play golf the rest of the time).

You chose medicine because it's something you have a passion for, something you have an aptitude for, and something you can commit to. You can make more money with less study, and fewer hours in law, finance, and business.

All of that said, if medicine didn't pay well, few qualified people would do it. Most of us are intelligent and hard-working and had other options besides medicine. I would not have spent 4 years of pre med, 4 years of med school, and 5 years of residency busting my rear end and going into 6 figures of debt in order to make $50K a year. It just wouldn't make sense. I'd also love to operate heavy machinery, but I didn't chose that field because I couldn't support my family.

So, of course most people consider the potential ultimate salary when chosing to enter medicine. Still, when you consider the hours involved, the sacrifice involved, and the debt accrued to get there, I don't think it's all that lucrative...at least Emergency Medicine isn't.

Your Med School cost $180,000!?!?!?!?!?Mine only cost Uncle Sam 25 large, thanks for makin me feel like a sucker.. I chose Medicine for one reason, it was the only way I could get attractive women to go out with me, legally that is. And I got a "D" in differential equations and had to give up my dream of bein a Nuclear Engineer...And what other job can you get paid to ride in FA-18s with 20/400 vision?? Even President Bush took crap for ridin in a crummy S-3 Viking, no gun, no afterburner, and its ugly, and not a cool A-10 or B-52 kind of ugly, the Sonia Sotomayor kind, where you have to sneak up on a clock to see what time it is.. And doctors were sayin the same thing in 1983, that when we practiced there'd be Nurses writing prescriptions, Robots doing Surgery, a Black Muslim in the Whitehouse, and jet cars like George Jetson flew. OK, 3/4 is pretty good.P.S. "Handshaking"??? Ewww... I haven't shaken hands with anyone with out 2 pairs of size 7 Biogel Super Sensitive surgical gloves protecting my epidermis in like forever...

The saddest part of this post is that those who NEED to hear it never will. Many others will read the words and chastise the bad, rich, selfish doctors for not being HAPPY to give away their services to unthankful idiots.

Any thoughts on the return of private practice without third party involvement? As a nurse, I would be more than happy to cough up more money to get personal care minus the CPT codes, AND not have to share the waiting room with morons who cannot or will not care for themselves and learn what does and does NOT constitute an emergency.

i know that my med school tuition was 26k/yr, add books, add rent, food, and hookers, then you easily get to 188.

as an aside, a residency classmate finished her four year ER residency with a combined undergrad and residency debt of 350k (two private schools, obviously)

Pattie,

surgical centers, boutique practices, cash for care, etc... are all happening now. if obama wants to truly carry through on this whole deal he will make it illegal to practice medicine and not take guv'mnt insurance. the market can move quicker than the government and will do so, but the government can stomp the market these days.

* For those of you thinking that medical school should therefore be ‘free’, please stop reading and go throw yourselves from a building more than 45 feet above pavement.

I am genuinely curious about this statement, so please don’t take my question the wrong way, but what’s the problem with tuition-free medical schools?

I live in a social-democratic Scandinavian country where all education is ‘free’. I use apostrophes because I’m well aware that the money to finance my ‘free’ education will later be repaid through my taxes, and so it isn’t actually free at all, only payment-delayed. However, this does mean that when I start my career after finishing medical school, I will have no bank deficit to pay off. And as taxes are calculated as percentages of income, rather than a fixed monthly amount, I automatically start out repaying my debt to society in small, affordable increments, without having to worry about interests being added on top.

I won’t be as highly paid as my American colleagues, but then I won’t have the same expenses, and with a 37-hour working week and 5 weeks of paid vacation a year by law, I’ll have time to raise my family. With no tuition to repay, no healthcare insurance necessary, and no malpractice insurance required, I’ll be able to buy a nice house, have a couple of cars if my husband is so inclined, and take maybe two vacations abroad a year. Granted, it won’t be a 15-bedroom mansion, and I won’t be taking my private jet on those vacations, but it’ll be an easy, comfortable life even so.

Compared to what I’ve read from you and Panda, this doesn’t seem so bad. Or am I missing something? Why is tuition such a crucial aspect of becoming a doctor that tuition-free medical schools are immediately ruled out? Please enlighten me.

Cecilie, no hard feelings, but our Med Schools aren't free cause we spent billions of dollars and millions of lives saving your POS country from the Nazis. Then we spent a few billion more protecting you pussies from the Russians. And how do you repay us?? OK, with Porn and Grolsch Beer, No hard feelings but your country peaked in the 9th century with the Vikings. I mean, you lost 2 Wars to the SWEDES!!!!!!!And we'll see how your career goes when the RagHeads take over and you have to wear a Burka and walk behind your A-rab husband on the way to the Bazarr to pick up some camel chops and betel juice.Did I tell you your country sucks?

For someone claiming to harbor no hard feelings, you sure do have a lot of hard feelings. It must be depressing to be so angry with the world all the time. Try smiling for once, I’m sure it’ll make you feel better. :)

Though entertaining to read, your rambling sadly left me no wiser with regard to my original question. To quickly address your attempt at hand-waving the issue before moving back on topic, Denmark will always be grateful for the aid we received from the Allied forces during and after WW2, but the Marshall Aid, while crucial for re-establishing Danish economy after the war, has had very little (if any) influence on our modern welfare system, and it certainly hasn’t impacted American economy nearly as much as the half dozen wars you’ve since waged. If American economy is struggling today, I think it’s hardly meaningful to point your accusing finger at 70-year old charity.

So, moving back on topic, why is it necessarily bad for medical schools (or indeed, any university education) to be tuition-free?

I don’t buy your argument that tuition-free medical schools are too expensive, because they’re funded through taxation; the more people that graduate and go on to earn a higher salary than they would have if left unschooled, the more money is put into the state coffers and then back into the university, which then produces even more/better graduates.

The Achilles heel of this system is of course the supply of graduates; if too many students fail to make it through, the university (and society) will lose money. That’s why universities here only choose the best of the best to attend; there is a fierce competition to be accepted for medical school and only top of the class students are allotted a seat. Perhaps for this reason, medicine is one of the university educations with fewest drop-outs (tied for first with law school). In Denmark, where all education is tuition-free and the only criteria for attending university are those of intelligence and diligent study, over 80% of university students graduate – in the USA the number is below 70% (source: OECD rapport ‘Education at a Glance’, 2009).

So if financial concerns aren’t a valid argument against tuition-free medical schools, what is then the issue?

Cecilie, and did I tell you I love that name?I didn't pay for med school either, except with my time, which I had alot of, still do, come to think of it.And if it wasn't for guys like my Dad, bombing the North Vietnamese into the Stoned Age, we'd never have beaten the Russians, and you'd be lucky to be on a 20 year waiting list to buy a crummy Russian copy of a crummy Italian car, instead of whatever BMW or Mercedes you drive(Somethin tells me Volvo's arent really popular in Danemark)And thats whats great about America, ANYONE can go to college, even Me, and we take India's best and brightest to, so don't act like your schools are so great, and when's the last time the Hague made a BCS Bowl??? Oh yeah, COPENHAGEN, excuse Me, and did you know in America "Copenhagens" a brand of chewing tobacco?? And even if your countrymen had the initiative to do anything about it, they couldn't cause your military's even smaller than Swedens, which might explain why you lost 2 wars to them. America's great, if I wanta wear a T-shirt with a cartoon of Moe-hammed wearing a Turban that looks like a bomb, I can do it, cause of the 2d Ammendment.But don't worry, we'll let you in when you want to start your lucrative Dermatology practice, or get tired of wearing that Burkha,

thanks for your question... i'm just catching all this stuff here... don't mind frank, he's a hell of a guy but can't resist the opportunity to fart (loudly) at the dinner table.

i could answer at great length but i won't bore you.

1. there is no such thing as 'free'. if your medical school is 'free', someone else is paying. if the government sends you to medical school for free, it's sending you with taxpayer money.

2. when the government does this, a single dollar taken from the taxpayer and transferred to the medical school ends up being a lot less than a dollar and the missing money goes to create paperwork and meaningless jobs.

3. this whole post is about personal responsibility... 'free' medical school will be the death knell of excellence in American medicine. it will no longer be a decision of great gravity. it will no longer attract the most qualified. it will be less of a challenge.

i kind of don't know what to say to what your responsibilities will be, but you are mistaken about some things...

1. i don't know a single physician who lives in a mansion. i live in a 3800 square foot house. i drive a truck. all of us are planning for retirement and funding it ourelves. we are not counting on the government for anything and, see below, i believe you are buying a pig in a poke if you are depending on the government for anything (even one such as yours... frank is poking fun at the muslim invasion, but ultimately something will have to give)

2. but even if you could show me a bunch of docs who lived in these mansions i would say, 'so what'? did they earn it? do they deserve it?

3. i think what you are having a hard time understanding is the still extant American spirit of competition. from what i'm reading the European pension system and cradle to grave socialism is on the precipice. don't go counting your chickens about what your life will be like. france is getting ready to raise the retirement age, greece is on the brink, and, if obama gets his way, you guys will not be able to relax under a nuclear curtain for much longer.

4. i don't blame you for liking your prospects... after all, i'm going to a job that, compared to what i've been doing, will be quite easy... 45 hour weeks and three weeks of vacation per year.

i forgot to reemphasize this because i don't think i made it clear... i make the extortion' argument not because i disagree with paying for medical school, but because EMTALA has changed the market pay scales... my family practice doc just took a 30% pay cut. THIRTY PER CENT. why? EMTALA and medicare/medicaid cuts... he has no choice but to say, 'okay' i'll take less (except to quit, or fire all his medicare and medicaid patients which is the same as quitting).

so, we signed on, the rules changed, and we are stuck with the deal we made... no one has cut our loan repayments by 30% and i DON'T' EXPECT THEM TO! it's the deal we made, we are simply asking for the other side to honor their side, but the other side is 'they', the government. it has no face. and it doesn't have a face in Scandinavialand either.

I am US citizen. I went to a Mexican Med School. I had no rights there and little academic rights back in the States. lol. I work for a community health center (semi socialized.) I do NOT get partnership etc. I make a Dentist's salary. I live in rent. Chose against "Wisteria Lane" since am single and you know our housing market! I drive a Ford Sedan and I DO travel but use our lousy airlines that treat us like Cattle (and I don't mean India's sacred cows!) In US we compete in things like Organic Chemistry are nerds six years slaves six years (MORE if we elect specialties.) Primary Care is a thankless job with all the smokers fatties addicts gomers crazies and etc. I didn't socialize much in High School either what with SATs grubbing for grades...

Mind you I DO condone socialized medicine, we cannot have all these poor uninsured folks. But Generalists need to get their due and we need sensible tort reform too.

I am glad that there are people who are willing to work in environments that you CHOSE to work in. Being your choice, you seem happy to work in that environment and therefore I commend you. It is your free choice that makes you happy with your practice.

I do not chose to work in your type of practice and would not want to be pushed into it by the Government.

I have always favored a plan whereby folks could CHOSE to work in your type of practice in exchange for a good salary and forgiveness of a certain percentage of their debt based on each year of service. This seems fair and already works in a limited number of areas.

Under Socialized Medicine with the Federal Government owning the student loans of virtually every non-military graduating physician, many of us can see the writing on the wall and the loss of CHOICE in practice type and location for "the greater good".

In my experience, the vast majority of US citizens who went to foreign medical schools did so because they could not meet the standards of the US schools. (One of the smartest guys I ever met went to med school in Mexico because he screwed around in college and he was a great doc).

About 50% of the patients I take care of do not pay, or barely pay (Medicaid). I don't mind taking care of the poor who legitimately need help. I DO mind taking care of those who just USE the system. You may not have a large percentage of these folks in your practice, but I do.

I commend you for being happy with your lot in life. But I chose my life, I have a family, and I don't make an exorbitant salary. I have to work every month to pay my bills just like everyone else and I'm tired of being demonized because a few medical specialists make a lot of money.

MDOD You are so right...I am one of those schmucks who got sucked in...As my last spasm of practicing medicine I did a one year contract with the US Army. Docs were fairly good in my specialty. They saw at the most 16 patients a day (breathing hard) A lot of time spent feeding AHLTA the DOD EMR....really sucks big time, unless you use Dragon Speech Recogniton. Best part the lab and CPOE whic yho can see right away.Anyway back to finances. Start earning money right away, CME paid for,lots of time off...meetings all the time, retire after 20 years, get pension...automatic transfer to A GS position, sock away the retirement, work 20 more years, second pension. Get benefits rest of yor life, disabiltiy coverage, vacation benefits, lots of perks being in the military..wife gets preferential treatment for government jobs. Was I a sucker to go into private solo practice.....Guess what we are all paying for it...

Dear anon, maybe she LIKES getting crapped on. And I don't have to listen to some snot-nosed-Med-Student-from-a-Euro-trash-communist-country-that-just-happened-to-fight-on-the-Nazi-side-and-lets-AlKaida-Terrorists-live-there-tell-Americans-how-much-we-Suck Frank

Thanks for the response, 911. Your response sounded a lot like what my primary care doc said to me. Ironically, he shoved a gun up my butt afterward to band some hemorrhoids so I couldn't see his face after he gave that advice.

As for the financial aspect, I'm already fairly knowledgeable. I'm actually 32 years old and work as a programmer for a company that makes software for hospitals. I've always wanted to do medicine, but it really wasn't until the last few years that I had the real maturity to pursue it with the fervor I'd need to devote to it.

The Danish government until now provided reimbursement for assisted reproduction treatments (ART) with up to three treatment trials for married and unmarried couples, singles and homosexuals.

In light of the need to prioritise public expenditure, the Parties agreed this month to implement a legislative amendment, so that Assisted Reproduction Treatment (ART) will no longer be part of the free public health services.

'This is sad news considering Denmark has always been praised as the benchmark in Europe in terms of access and availability of treatment for patients seeking ART' said Dr. Søren Ziebe from the University Hospital in Copenhagen, Executive Committee Member of ESHRE and the SIG coordinator of all SIGs at ESHRE.

The Danish government has allocated a pool of a mere 50 million Danish Krone (approximately 6.7 million Euros) for groups with special needs only. The cuts in this area will decrease government spending by 200 million Danish Krone (EUR 26.9 million) annually in 2011, 2012, 2013 and thereafter.

In 2007, 4.9% of all children born in Denmark were babies conceived with the help of ART, according to the ESHRE European IVF Monitoring Group (EIM). With 2,558 cycles per million inhabitants annually, Denmark has the highest availability of ART in Europe. 'Every school class in Denmark has two IVF children on average' said Dr. Ziebe. 'These changes will have major implications and detrimental effect for childless couples, for fertility clinics and the research environment in Denmark.'

For more information please view the document released by the Danish authorities (in Danish only) at:http://www.eshre.eu/page.aspx/1020